Coverage of Autism under Health Insurance

The Autism Society of North Carolina believes that people should have access to affordable health care that includes treatment and services that address Autism Spectrum Disorder. The United States has a fragmented health-care system that is based on an insurance model. Health-insurance plans are purchased by individuals, employers, the government or a combination of these. Every plan provides a different set of health-care services, though most are required to provide a basic benefit package that includes things like diagnosis, preventive care, doctors’ visits, mental-health services, and emergency care. Individuals are responsible for paying part of the cost of care with premium payments, co-pays, deductibles, and/or co-insurance.

Depending on the kind of health-insurance plan a person has and the source of the health insurance, different laws apply. The federal government (Congress and the administration) determines laws and regulations for insurance plans for federal employees and retirees, the military, railway employees and retirees, Medicaid, Medicare, and private companies that self-insure* or those that operate in more than one state or country. Generally, large, private companies are regulated by the federal government, and state health-care laws do not affect them. State government (the General Assembly, or state legislature, and the governor’s administration) regulate health-care laws for companies that operate only in a particular state and who purchase group health-insurance plans for their employees, as well as health-insurance plans directly sold to individuals in that state.

The exception to this rule is plans sold on the health-care marketplace or health-care exchange under the Affordable Care Act. These are individual plans regulated by the federal government as well as by states. State laws apply to them; state laws passed prior to December 31, 2010, are grandfathered into those plans. Laws passed after that date that require insurance companies to add benefits do apply to ACA plans, but the state itself must pay for the cost of additional coverage and cannot pass the cost onto the federal government or insurance companies. States that do not want to cover the cost of additional coverage are either not passing new laws or are exempting those ACA plans from required coverage.

The Autism Society of North Carolina and its partner organizations helped pass legislation in North Carolina in 2015 that will require plans sold in North Carolina to cover autism treatment. For FAQs on the new law, please click here. Several types of plans would NOT be covered by the law: group plans sold to large companies that operate in more than one state, military health care, Medicaid, Medicare, the State Employees Health Plan for state and local employees, and plans sold on the health-care exchange under the ACA. Some of these plans cannot be regulated by state law and others have been exempted from the law. The State Employees Health Plan sets its own benefit package and has already voluntarily adopted an autism treatment benefit, so their benefit may differ from other plans covered under any new law.

Even though state laws cannot require every plan to cover autism treatments, once a law like this has passed, many companies that are not covered will voluntarily adopt coverage for their employees who live and work in that particular state.      


*Self-insured health plans: Some companies provide their own health-insurance plans under a self-insurance model. In this, the company is its own insurance “company” and pays the health-care costs of its employees directly rather than paying insurance premiums to an insurance company. While these companies might use a medical management company to deal with bill payment and customer service, as well as contract with them to provide a network of providers, these companies are still paying for the health care directly and not paying health-insurance premiums. Some companies will carry additional insurance to cover their losses in potentially catastrophic health-care cases.